Renal And Urinary Tract Flashcards
Significant changes
Kidneys become larger
Inc plasma flow and GFR 40-65%
R Dilatation of renal calyces and ureters - progesterone and mechanical obstruction
Vesicoureteral reflux - incompetence due to bladder flaccidity
UA
Occasional glucosuria
Unchanged in normal pregnancy
Abnormal proteinure
> 300mg/day
Albumin protein excretion
5-30 mg/day
+1 or greater blood on urine dipstick when screened before 20 weeks
Risk for developing preeclampsia
Idiopathic hematuria
2 fold
Serum creatinine threshold
> 0.9 mg/dl (75 umol/L)
If persistent, consider intrinsic disease
Done for recurrent UTI, hematuria, polyps, stones, tumors or cancer in urinary tract
Cystoscopy
Done for stone removal during pregnancy
Ureteroscopy
Renal biopsy
Postponed until postpartum 7% chance of complication
Most common bacterial infection during pregnancy
Asymptomatic bacteriuria
Asymptomatic bacteriuria risk is inc because
Mechanical and hormonal changes promoting urinary stasis and vesicoureteral reflux
Short urethra
Improper perineal hygiene
90% of non-obstructive pyelonephritis is caused by
E coli
Present in E coli that enhance bacterial adherence and inc their virulence
P fimbriae
S fimbriae
adhesins
surface proteins
Risk factors that predispose woman to UTI in puerperium
Dec bladder sensitivity to intravesical fluid tension
Dec bladder sensation to distention
Do IE before discharge!!
If patient cannot walk postpartum, it is due to
Hematoma
Urinary retention
Risk factors that increase likelihood of retention
Primiparity Perineal laceration Oxytocin-induced or augmented labor Operative vaginal delivery Cathteterization during labor Labor >10 hours
Asymptomatic bacteriuria Dx
Urine culture >100,000
Treat bec of high chance of developing symptomatic infection (20,00-50,000)
Dec incidence pyelonepritis
Screening for bacteruiria on first visit recommended
Asymptomatic bacteriuria Tx
Single dose Amoxicillin 3g Ampicillin 2g Cephalosporin 2g Nitrofurantoin 200mg TMP-SMZ 320/1600
3 day course
Same as above
Ciprofloxacin 250
Levofloxacin 250
When dispensed during later course 30 days before delivery, has been linked to inc risk of neonatal jaundice but overall teratogenic potential is LOW
Nitrofurantoin
Cystitis and Urethritis Tx
3 day course Amoxicillin 500mg Ampicillin 250mg Cephalosporin 250mg Ciprofloxacin 250mg Levofloxacin 250mg Nitrofurantoin 50-100mg TMP-SMZ 160/800mg
Lower urinary tract symptoms
Pyuria
Sterile urine culture
Urethritis from Chlamydia trachomatis
Chlamydia trachomatis Tx
Azithromycin
Most common serious medical complication of pregnancy
Leading cause of septic shock
Fever, chills and flank pain
Leukocytes in clumps
Numerous bacteria
Most occur in 2nd trimester
Unilateral, right sided
Renal infection
Rf:
Nulliparity
Young age
70-80% of infections
Most common organism
E coli
Kleb 3-5%
Enterobacter or proteus 3-5%
Gram + (Group B strep and staph)
Should be monitored in pyelonephritis because 20% of women develop renal dysfunction
reduced to 5% if aggressive fluid management done early
Creatinine
Pyelonephritis Tx
Admit
Urine and blood culture
Hemogram, serum crea and electrolytes
Cath (24 h urine collection)
UO >/= 50ml/hr with IV crystalloid
IV antibiotics - oral, and discharge if afebrile more than 24h
Repeat urine culture 1-2 weeks after
Cornerstone of pyelonepritis tx
IV hydration
Fever should be controlled in pyelo because of possible
Teratogenic effects
Do renal UTZ if there is
persistence of fever >3 days
Rule out obstruction
Last option, MRI
Identifies 90% of renal calculi
Plain Ab
Modified one-shot IVP
Stent to relieve obstruction and left in place until delivery
Patchy interstitial scarring
Tubular atrophy
Loss of nephron mass
Chronic pyelonephritis because of vesicoureteral reflux
Long term complication: Hypertension
Reflux Nephropathy
80% of stones
Polygenic familial idiopathic hypercalciuria
65-75% of stones in pregnancy
Low calcium diet promotes stone formation
Calcium salts
Calcium phosphate
Calcium hydroxyapatite
Nephrolithiasis Tx
Hydration
Diet low in sodium and protein to prevent recurrence
Thiazide diuretics
Indication for removal of stones
Obstruction (very painful)
Infection
Intractable pain
Heavy bleeding
Nephrolithiasis removal in pregnant
Flexible basket via cystoscopy
Ureteroscopic removal
Ureteral stent
Percutaneous nephrostomy
Contraindicated for removal of neprolithiasis in pregnant
Lithotripsy
Pain increases risk for contraction leading to preterm birth
Pain in 90% Gross hematuria UTZ One shot pyelogram (to see stones in ureter) CT scan only postpartum
Nephrolithiasis
This drug should be stopped in renal transplant patients if they want to get pregnant because teratogenic
6 weeks prior to conception
Mycophenolate mofetil
Incidence is high in all transplant patients
Preeclampsia
GDM
Most frequent viral infection following renal transplant
Polyomavirus hominis 1
BK
Autosomal dominant
Ciliopathy
Hypertension in 70%
Progression to renal failure
Involves liver, heart and brain
Polycystic kidney disease
HTN Hematuria Red cell cast Pyuria Proteinuria
Nephritic
Most common nephritis syndrome
IgA Nephropathy Berger disease
Proteinuria Hypoalbuminemia Hypercholesterolemia Edema Hypertension
Renal biopsy if etiology to be determined
Vulvar edema
Chronic HTN
PreEclampsia
Nephrotic syndromes
Pregnant undergoing dialysis
Multivitamin doses doubled
Calcium and iron salts provided
Chronic anemia with epo
Extra calcium to diasylate with less bicarbonate
High morbidity
High mortality
Sudden impairment of kidney function with retention of nitrogenous waste and other waste products normally excreted by kidneys
Severe pre eclampsia and hemorrhage HEELP Septicemia Acute fatty liver in pregnancy Dehydration from hyperemesis gravidarum Thrombotic microangiopathy
AKI
Most common outcome following AKI
Preeclampsia 70%
Important sign of acute impaired renal function
Oliguria
Contraindicated in treatment of oliguria
Loop diuretics
AKI is most often due to
Acute blood loss associated with preeclampsia
Originate from an enlarging paraurethral gland abscess that ruptures into urethral lumen
Urethral diverticulum
Urethral diverticulum Tx
Expectant during pregnancy
MRI if necessary
Caused by McDonald
cerclage
prolonged obstructed labor
Vesicocervical fistula
